Table of Contents
- I. Introduction
- II. Applicable Rules and Definitions
- III. Programs and Services
- IV. Payment
- V. Provider Eligibility Criteria
- VI. Provider Requirements
- VII. Special Conditions
This document serves as an attachment to the Illinois Department of Human Services (DHS) Community Services Agreement and sets forth supplemental contractual obligations between the Provider and the Department. The Attachment provides contractual requirements beyond those in the Agreement and is intended to clarify programmatic areas of the Department of Human Services Division of Mental Health (DHS/DMH) programs. Providers are strongly advised to consult the DHS/DMH Provider Manual for additional information on requirements and guidelines regarding the delivery of and payment for services under this contract. The DHS/DMH Provider Manual is incorporated into this attachment by reference and is made part of the contract and attachment requirements.
II. Applicable Rules and Definitions
The Provider shall comply with all applicable federal, state and local rules and statutes, including, but not limited to, the following:
- Block Grants for Community Mental Health Services, Subp. I & III, Part B, Title XIX, PHS Act/45 CFR Part 96;
- Medicaid (42 U.S.C.A. 1396 (1996);
- 42 CFR 440 (Services: General Provision) and 456 (Utilization Control) (1996);
- Health Insurance Portability and Accountability Act (HIPAA) as specified in 45 CFR, Section 160.310.
- Title XX of the Social Security Act, 42 USC 1397 et. seq.
- 45 CFR Part 96 (Block Grants) Subpart B, C, and G
- HITECH Act - 42 CFR: Parts 412, 413, 422, and 495, 45 CFR: Subtitle A Subchapter D
- Patient Protection and Affordable Care Act (PPACA), Public Law 111 - 148
- More information on Federal Rules and Codes may be obtained on the internet at the following address: (http://www.gpoaccess.gov/cfr/index.html)
- Campus Security Enhancement Act of 2008 (110 ILCS 12/1)
- Mental Health and Developmental Disabilities Code (405 ILCS 5);
- Community Services Act (405 ILCS 30);
- Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110);
- Save Medicaid Access and Resources Together (SMART) Act (097-0689)
- 59 Ill. Admin. Code 50, Office of Inspector General Investigations of Alleged Abuse or Neglect in State-Operated Facilities and Community Agencies;
- 59 Ill. Admin. Code 51, Office of Inspector General Adults with Disabilities Project;
- 59 Ill. Admin. Code 103, Grants;
- 59 Ill. Admin. Code 115, Standards and Licensure Requirements for Community Integrated Living Arrangements;
- 59 Ill. Admin Code 117, Family Assistance and Home-Based Support Programs for Persons with Mental Disabilities;
- 59 Ill. Admin. Code 125, Recipient Discharge/ Linkage/Aftercare;
- 59 Ill. Admin. Code 131, Children's Mental Health Screening, Assessment and Supportive Services Program;
- 59 Ill. Admin. Code 132, Medicaid Community Mental Health Services Program;
- 59 Ill. Admin. Code 135, Individual Care Grants for Mentally Ill Children;
- 89 Ill Admin Code 130, Administration of Social Service Programs
- 89 Ill. Admin. Code 140, Medical Payment;
- 89 Ill. Admin. Code 140.642, Screening Assessment for Nursing Facility and Alternative Residential Settings and Services;
- 89 Ill. Admin. Code 507, Audit Requirements of Illinois Department of Human Services;
- 89 Ill. Admin. Code 509, Fiscal/Administrative Record keeping and Requirements;
- 89 Ill. Admin. Code 511, Grants and Grant Funds Recovery;
- More information on State Statutes and Rules may be obtained on the internet at the following address:
- http://www.ilga.gov (For Statutes select "Illinois Compiled Statutes", for Rules select "Administrative Rules")
- Manuals and Handbooks
The Provider shall comply with all applicable requirements for services and service reporting as specified in the following Department manuals and/or handbooks:
- DHS/DMH Provider Manual
- DHS Mental Health CSA Program Manual
- DHS/DMH PAS/MH Manual http://www.dhs.state.il.us/OneNetLibrary/27896/documents/PreAdmissionScreen-MH-Manual.pdf
- Community Forensic Services Handbook http://www.dhs.state.il.us/OneNetLibrary/27896/documents/Contracts/Forensic%20Training%20Manual%20%20(UST).pdf
- Community Mental Health Service Definitions and Reimbursement Guide. http://www.dhs.state.il.us/page.aspx?item=32626
- Handbook for Providers of Screening Assessment and Support Services, Chapter CMH-200 Policy and Procedures For Screening, Assessment and Support Services http://www.hfs.illinois.gov/assets/0708sass.pdf
III. Programs and Services
Through this agreement with the Provider, the Department purchases one or more mental health programs or services, which are to be provided and then reported or billed to the Department and/or HFS under the following broad categories.
- Services Purchased by Fee-for-Service
- Medicaid Services
- Non-Medicaid Services/Oral Interpretation
- Non-Medicaid Enhanced
- Pre-admission Screening and Resident Review for Persons with Mental Illness (PAS/MH; Cost Center 790)
- Individual Care Grant (ICG) Services
- Community Hospital Inpatient Psych Services (Cost Center 550)
- Outreach (Cost Center 710)
- Transition Coordination Non-Billable (Cost Center 780)
- Clinical Review (Cost Center 790)
- Residential Review (Cost Center 795)
- Capacity Grant Programs
- This contract may include grant funding for programs or portions thereof that involve some services and activities that have not been converted to a fee-for-service basis.
- The Provider's obligation in receiving capacity grant funds is to expend the funding for allowable expenses required to meet the program's objectives or reconcile with services based on Exhibits in the contract and to report to the Department on appropriate deliverables. As it meets the program objectives, a Provider may determine that some program activities supported by these grant funds are billable services. However, when a Provider bills for an activity under a capacity grant program, the Provider is not to report the activity or the expenses as part of the grant funded deliverable, as this would result in counting the activity more than once in meeting the Provider's obligation.
- The Department must track capacity grant awards through its accounting system, please see the Community Services Agreement, Exhibits A-C for funding amounts. In the reconciliation of allowable expenses, the Department expects the provider to demonstrate allowable expenses for the total of these lines for each program, not portions of the award that may be associated with specific accounting service codes or Provider service sites.
- The programs that comprise capacity grants vary among Providers, and not all Providers are currently funded for each of these programs. Full description of capacity grants programs are located in Exhibit A of the appropriate contract. Funded capacity grant programs include:
- Mental Health Juvenile Justice (Cost Center 121)
- Psychiatric Leadership (Cost Center 350)
- Capitated Community Care (Cost Center 410)
- Eligibility and Disposition Assessment (Cost Center 420)
- Crisis Assessment and Linkage (Cost Center 440)
- Discharge Linkage and Coordination of Services (Cost Center 450)
- Outreach to individuals to engage in services (Cost Center 460)
- Special Projects (Cost Center 510)
- Specialized Direct Clinical Services (Cost Center 515)
- Psychiatric Medications (Cost Center 574)
- PATH Grant (Cost Center 575)
- Crisis Services (Cost Center 580)
- Community Integrated Living Arrangement (CILA Cost Center 620)
- Medicaid Spend-Down (Cost Center 700)
- Drop-in Center (Cost Center 720)
- Quality Administrator (Cost Center 730)
- ACT Start Up (Cost Center 740)
- CST Start Up (Cost Center 750)
- Intergrated Health Care (Cost Center 760)
- Individual Placement & Support (Cost Center 770)
- Transitional Living Centers (Cost Center 811)
- Supported Residential (Cost Center 820)
- Supervised Residential (Cost Center 830)
- Transitional Supervised Residential (SMHRF Comp, Cost Center 831)
- Reintegration Residential (Cost Center 840)
- Crisis Residential (Cost Center 860)
- Crisis Residential (SMHRF Comp, Cost Center 861)
The capacity grant services listed below must meet the following guidelines:
- The ratio of expenditures for the delivery of services and related activities to administrative costs shall be in accordance with the standards established in the Community Services Agreement and the Provider Manual.
- Capacity Grand funds may be used to provide capacity services for individuals enrolled in the Managed Care Initiatives. In the event that the Managed Care Initiatives begin making payments for capacity services, no additional funding will be provided by DMH for these services.may be used to provide capacity services for ICP Enrollees. In the event that the ICP entities begin making payments for capacity services, no additional funding will be provided by DMH for these services.
- DHS/DMH will specify any additional reporting requirements.
- Donated Funds Initiative/Local Initiative Funds / Title XX
- Services and Programs covered by the federal Social Services Block Grant are included in the Donated Funds Program. If you have any questions or require further information, please contact DHS Division of Human Capital Development at (312) 793-0683 or (217) 785-3300.
Top of Page
- Payment for Fee-for-Service
- Services paid on a fee-for-service basis are reimbursed after the services are delivered. Payments are made based on a bill or claim from the Provider containing the appropriate service documentation as directed by the Department and/or the Illinois Department of Healthcare and Family Services. Third party payers must be billed prior to DMH due to the fact that DMH is the payer of last resort. Payment for non-Medicaid services will not be paid in excess of the contract amount.
- Providers are prohibited from submitting Medicaid, Non-Medicaid, and ICG claims to the Department for any services delivered to enrollees in the Integrated Care Program.
- Payment for Capacity Grants
- Capacity grants are usually made on a monthly basis.
- Payment for Special Projects
- The Department may adopt a different payment schedule, reporting requirements, and monitoring activities for special projects. The details of these special projects will be specified in an exhibit describing the scope of service for the special project and will be on file with the Department.
- Providers are prohibited from using allocated funds or submitting Medicaid and Non-Medicaid claims to the Department for any Special Project services delivered to enrollees in the Integrated Care program.
- Other Payment Conditions
- Debt Service Deduction
- If the Department approves the Provider's request for a debt service deduction contract (pooled loan program or other loan program) the Provider hereby authorizes the Department to deduct the Provider's debt service payments from the Provider's award and forward payment directly to the trustee bank or other designated party. Participating Providers agree to execute a debt service deduction contract in the form provided by the Department.
- If the Provider desires to participate in such a deduction contract, the Department shall receive ninety (90) days written notice from the Provider of its intention to enter into pooled loan financing, or any other financing transaction which would require the use of a debt service deduction mechanism by the Department. If the Provider fails to provide such notice, the Department shall not execute any debt service deduction contracts until the Department has had ninety (90) days for project review. The Department has the right of approval of all financed projects where the Department will perform the debt service deduction.
- The Provider shall supply to the Department an estimated debt service deduction payment schedule thirty (30) days before closing of the loan transaction.
- Additionally, Providers specifically acknowledge that if they enter into a debt service deduction contract to secure a loan based upon fee-for-service funding, such funding is based upon individuals receiving services, each authorized for service or placement by the Department, at rates set by the Department. Accordingly, if and when funding for a particular individual receiving service terminates, the Department does not guarantee replacement of equivalent funds. Therefore, any such debt service deduction contract will be honored only to the extent of currently supported fee-for-service funding at the time of any debt service deduction.
- Full Year Service Delivery
- The funds obligated under this total annual award are intended by the Department to support programs and services for individuals for the entire twelve-month period of the State fiscal year referenced herein. The Provider shall ensure that all programs and services funded by this award are available for the entire twelve-month period of the fiscal year regardless of when full disbursement of the award occurs (unless prior written authorization is obtained from DHS/DMH). The Department reserves the right to stop all payments to Providers who cease providing programs and services during the contract year without the prior written approval of the Department
- Funding Reserves
- The Department maintains the right to reserve funds in this contract based on budgetary considerations. Providers subject to reserves will be notified in writing of the amount and duration of the funding reserve.
Top of Page
V. Provider Eligibility Criteria
- Providers that receive $200,000 or more annually in funding from the Division of Mental Health for mental health services, or that have a residential or ICG program are required to have their funded mental health services, including residential and ICG programs/services nationally accredited. Accreditation may be by one of the following national accreditation entities: The Council; CARF, The Rehabilitation Commission; The Joint Commission; Council on Accreditation of Services for Families and Children; or American Osteopathic Association, Healthcare Facilities Accreditation Program. As evidence of the accreditation, Providers will submit to the DHS Bureau of Accreditation, Licensure and Certification a copy of their current accreditation certificate, accreditation report, and all correspondence about corrective actions required to maintain accreditation status.
- Medicaid Certification
- Providers delivering community services to consumers and receiving funding under this contract must be:
- certified under 59 Ill. Admin. Code 132, and
- enrolled with the Department of Healthcare and Family Services
- Providers delivering services to consumers must be Enrolled with the Department of Healthcare and Family Services.
- Forensic Services
- Providers delivering court-ordered forensic services must comply with 725 ILCS 725 5/ 104-15,104-16, 104-17 and 104-25 and 730 ILCS 5/5-2-4 and the provisions of the DHS/DMH Community Forensic Handbook. Providers must also participate in DHS/DMH forensic-specific training prior to offering forensic services as well as ongoing training offered by DHS/DMH.
Top of Page
VI. Provider Requirements
- Providers under contract shall utilize the reporting of functional standardized assessments based on the guidelines in the Provider Manual.
- Providers are required to clinically manage services consistent with medical necessity and clinical care guidelines. Providers shall comply with all utilization management and authorization policies and procedures described in the DHS/DMH Provider Manual, including the submission of requests for authorization and the provision of clinical documentation and other information necessary to confirm the medical necessity and benefits of the requested service.
- The Provider is required to submit complete and accurate claims and encounter claims and data concerning the operation of its funded programs as directed in the Provider Manual, this Attachment, and/or it's exhibits. Providers are required to submit client registration information for all consumers including those enrolled in managed care organizations (MCO) or other managed care initiative programs.
- The Provider in consultation with the DHS/DMH Regional Office will cooperate in maintaining and updating the DHS/DMH Provider Database.
- The Provider is required to preserve consumer access to service. Therefore, Providers may not close a site or relocate a site where DHS/DMH funded services are provided without obtaining approval from DHS/DMH.
- Populations to be Served:
- Providers are required to serve individuals as described in the Provider Manual.
- Providers are required to work collaboratively with DHS/DMH Regional Offices to plan services for individual consumers who do not meet the criteria, but who are:
- Referred to or from a DHS/DMH state hospital;
- Referred from the Office of Inspector General's Adults with Disabilities Abuse Project;
- Remanded to the Department and adjudicated as either unfit to stand trial (UST) or not guilty by reason of insanity (NGRI) and for whom state hospital inpatient services are unnecessarily restrictive;
- Transitioning from Long Term Care facilities.
- For all of the above populations, substance abuse as a co-occurring or secondary diagnosis is not a basis for exclusion from mental health services, but rather deserves special consideration in the delivery of services, including the integrated delivery of services when possible.
- Consumers receiving DHS/DMH funded services who are Limited English Proficient (LEP) will be offered services by bilingual staff or by interpreters.
Top of Page
VII. Special Conditions
- Central Registry and Background Checks
- Nurse Aid Registry
The Provider shall not employ an individual in any capacity until the Provider has inquired of the Department of Public Health as to information in the Nurse Aide Registry concerning the individual. For new employment applicants, if the Registry has information substantiating a finding of abuse or neglect against the applicant, the Provider shall not employ him or her in any capacity. For currently employed staff, if the Registry has information substantiating findings of abuse or neglect, the Department will expect the Provider to act in accordance with its personnel policies and procedures, and take steps to ensure the protection of individuals served by the Provider as deemed appropriate.
- Health Care Worker Background Check Act.
The Provider certifies that it is in compliance with all requirements and regulations issued pursuant to the Health Care Worker Background Check Act (225 ILCS 46).
- Reporting and Investigating Incidents and Allegations of Abuse and Neglect
- Provider Requirements
- The Provider shall develop and implement a policy and procedure on Reporting and responding to Abuse and Neglect ensuring reporting incidents as required by 59 Ill Admin Code, Ch. 1, Part 50 including definitions of abuse and neglect, screening prohibition, time frames for reporting and preservation of evidence and best practice response to disclosure,
- The Provider shall ensure that all OIG liaisons successfully complete the DHS/OIG Basic Investigative Skills training and then every two years thereafter,
- The Provider shall ensure that the individual, as well as well as the parent or guardian are notified regarding an individual's involvement when an allegation is under investigation by the Office of the Inspector General,
- The Provider shall have a formalized ongoing systemic review process at least quarterly for evaluating all injuries, including those not definable as abuse and neglect, including and not limited to deaths, suicide attempts, and other adverse events within the agency. The review processes shall include, but are not limited to:
- Examining the circumstances and data to determine how and why the injury or other adverse event occurred, including determining all related processes and systems;
- Identifying risk points and their potential contribution to the event, such as evaluating the appropriateness of the individual's treatment plan and level of supervision;
- Identifying, communicating, documenting, implementing, and evaluating improvements in processes, systems, or treatment to prevent future such injury or other adverse event, including specifying:
- The staff responsible for implementation;
- When the actions will be implemented; and
- How the effectiveness of the action will be evaluated.
- It is the policy of the Division of Mental Health that all requirements pertaining to the reporting of licensed health care practitioners to the Illinois Department of Financial and Professional Regulation (IDFPR) and the National Practitioners Data Bank be followed. The Provider shall make such reports when and to the extent required by law.
- The Provider shall endeavor to reinforce the responsibility of health care practitioners to report appropriate matters to IDFPR by such actions, as it deems reasonably necessary, including posting notice that individual practitioners shall comply with applicable licensing and reporting requirements.
- Representative Payee Support
For individuals receiving DMH services under this contract, the Provider shall, if clinically appropriate and as directed by a physician, serve as representative payee or arrange for representative payee for benefit payments under the Social Security Disability Insurance program and/or the Supplementary Security Income program.
For each individual receiving representative payee support, the Provider will ensure that the individual's treatment plan includes goals, objectives and rehabilitation interventions designed to build the skills needed for the individual to progress toward self-management of their own funds.
Where the Provider will function as the representative payee of record, the Provider may be compensated for administrative and clerical support activities related to the management of funds per the rules and procedures of the Representative Payee Program of the Social Security Administration. Information about the SSA Payee Program is available at: http://www.ssa.gov/payee/.
- The Provider shall allow the Department or its agent access to its facilities, records and employees for the purposes of monitoring this Agreement. The Department or its agent will monitor compliance with the conditions specified herein. However, for conditions specifically covered by accreditation standards, the Provider's current accreditation status with full compliance on all relevant standards (as submitted per section V.A.) of this agreement) is accepted by the Division of Mental Health in lieu of administrative and program monitoring requirements (per 405 ILCS 30/3). (Licensure and certification reviews per 59 Ill Admin Code 115 and 132 will continue to provide deemed status as currently included.)
- Performance Measures: The Provider shall provide all provider data for performance outcome measures at the request of the Department.
- Data and Data Security
- The Provider shall adhere to DHS policies and procedures for submitting data to the Department and for maintaining data security for all data submitted to, or received from, the Department.
- Individual and Family Input and Participation
- The Provider shall have policies and practices which reflect formal mechanisms, which ensure the outreach toward, and participation of individuals, their families, and/or other interested parties in the planning, development, delivery, and evaluation of and satisfaction with clinical services.
- Providers are expected to educate individuals receiving services or the parent/guardians of children/youth receiving services toward participation in developing their plan for care, treatment and services including a crisis plan. The individual's, child's parent/guardian's, and when appropriate, youth's participation in developing his or her plan for care, treatment, services, and crisis plan is documented on the individual treatment plan as well as a separate note in the individual's clinical record. The note includes the Provider's process for involving individuals, and child/youth parent/guardians in their care, treatment, and service decisions. The process shall consider and respect the individual's, and parent/guardian's and youth's views. All efforts to involve individuals in consumer-generated crisis planning are to be made and documented before employing a provider-generated crisis planning. Provider-generated crisis planning is to be replaced with consumer-generated crisis plan that is consistent with trauma-informed care. A copy of the written treatment plan will be provided to the individual, parent/guardians and youth. The expectation is that services delivered to children will be Family Driven, as defined by the Federal-Substance Abuse Mental Health Services Authority.
- DHS/DMH Individual and Family Grievance Process
- In addition to maintaining an internal process for receiving and responding to grievances from individuals, families or members of the community, DHS/DMH Providers contracted to deliver community-based mental health services (i.e., excluding PAS/MH, and ICG Providers) shall make available the DHS/DMH Consumer and Family Handbook and contact information for the DHS/DMH grievance process.
- Requests for Information
- The Provider shall respond to a request by the Department for general information (for example, a legislative inquiry) within ten (10) working days of the written request for information. For emergency forensic inquiries, the Provider shall respond within forty-eight (48) hours of receipt of the request.
- Federal Mental Health Services Block Grant Funds
- Federal Mental Health Services Block Grant funds (CFDA 93.958) allocated to a mental health grant Provider shall not be used for the following:
- To provide inpatient services;
- To make cash payments to intended recipients of health services;
- To purchase or improve land, purchase, construct, or permanently improve (other than minor remodeling) any building or other facility; or purchase major medical equipment;
- To satisfy any requirement for the expenditure of non-Federal funds as a condition for the receipt of Federal funds; or
- To improve financial assistance to any entity other than a public or nonprofit public entity.
- Federal Housing Development
- The Provider agrees to notify the DMH Housing Coordinator thirty (30) days in advance of making any application to the federal Department of Housing and Urban Development (HUD) for HUD Section 811 or Continuum of Care programs for community-based Permanent Supportive Housing development funding for persons with mental illnesses.
- The Provider further agrees not to include the Department as a funding source on any application without the express written consent of the DMH Housing Coordinator.
- Consumer Registration Information
- The Provider shall ensure that consumer registration data on file with the Department or its agent are complete and are updated per department requirements to accurately reflect for each consumer receiving services their current status and condition, including information on diagnosis and functional capacity, whenever the consumer's treatment plan is updated or the Provider discontinues serving the consumer. For required data elements refer to the Provider Manual.
- Continuity of Care
- Continuity of care is a core tenet of responsible community mental health care. The Provider is required to participate in a continuity of care planning process with the local Region Office to clarify how the Division resources can be used in a coordinated way to minimize barriers between and among inpatient, outpatient, emergency room, and other key health care boundaries in the local community. The local Region Office will facilitate this planning process during the fiscal year. Written guidance on the planning process can be found on the DMH website.
- Disaster Response
- In the event of a State-declared disaster, agencies funded through this contract for Medicaid, Non-Medicaid, and/or capacity grant programs shall participate in training for, and response to, a DHS/DMH activated emergency response plan.
- Evidence-based Practices
- Providers receiving a contract or who are under another business agreement with DHS/DMH to provide evidence-based practices must demonstrate fidelity to evidence-based practice models.
- Distribution of Materials to HFS or DHS/DMH Eligible Individuals
- DHS/DMH or its agent may develop and produce electronic and paper products designed to inform individuals about services, benefits, rights or the service delivery system such as updated copies of the DHS/DMH Consumer and Family Handbook, notices for consumer and/or family telecalls. Providers shall assist DHS/DMH or its agent with distributing these materials by placing or posting copies of written material produced and provided by DHS/DMH or its agent in waiting areas, and by notifying individuals of available electronic information by providing and posting the website address for the information starting at the time of registration/enrollment and continuing throughout the consumer's service contract.
Top of Page